RESEARCH AND PRACTICE
Asian American Women in California: A Pooled Analysis of Predictors for Breast and Cervical Cancer Screening Neetu Chawla, PhD, MPH, Nancy Breen, PhD, Benmei Liu, PhD, Richard Lee, BS, and Marjorie Kagawa-Singer, RN, PhD, MA, MN
Cancer is the leading cause of death among Asian American women, with breast cancer and cervical cancer being 2 of the most commonly diagnosed types of cancer among this population.1---6 Although Asian American women have lower mortality rates for breast cancer compared with women from other racial/ethnic groups, existing research suggests that they have later cancer stage at diagnosis,3 younger age at diagnosis,7 and poorer survival among certain subgroups.8,9 Notably, studies have highlighted significant variation in cancer risk factors and differential cancer burden among Asian nationalities.4---6 Therefore, researchers have increasingly made efforts to disaggregate data on Asian Americans for analyses to identify subgroup differences. In one study conducted in California, McCracken et al.10 found that Vietnamese women had the highest mortality rates for cervical cancer, whereas Filipino women had the highest mortality rates for breast cancer. Another study conducted by Bates et al.11 found that Vietnamese and Korean women had the highest rates of cervical cancer mortality compared with other Asian women and White women. Despite a clear need for cancer screening among all Asian American women, their screening rates for breast and cervical cancers remain well below national objectives promoted by Healthy People 2020.12,13 Miller et al.2 found that 73.7% of all Asian women reported a mammogram in the past 2 years— nearly 10% lower than the Healthy People 2020 objectives of 81.1%, and lower than all other racial/ethnic groups except for American Indians or Alaska natives.12 In addition, Asian American women consistently have the lowest rates of cervical cancer screening, with 65.6% reporting a Papanicolaou (Pap) test in 2008.2 This rate was almost 10% lower than screening rates for White women and nearly 30% lower than the national recommendation of 93.0%.12 Additional research has noted that these disparities in breast and cervical cancer
Objectives. We examined patterns of cervical and breast cancer screening among Asian American women in California and assessed their screening trends over time. Methods. We pooled weighted data from 5 cycles of the California Health Interview Survey (2001, 2003, 2005, 2007, 2009) to examine breast and cervical cancer screening trends and predictors among 6 Asian nationalities. We calculated descriptive statistics, bivariate associations, multivariate logistic regressions, predictive margins, and 95% confidence intervals. Results. Multivariate analyses indicated that Papanicolaou test rates did not significantly change over time (77.9% in 2001 vs 81.2% in 2007), but mammography receipt increased among Asian American women overall (75.6% in 2001 vs 81.8% in 2009). Length of time in the United States was associated with increased breast and cervical cancer screening among all nationalities. Sociodemographic and health care access factors had varied effects, with education and insurance coverage significantly predicting screening for certain groups. Overall, we observed striking variation by nationality. Conclusions. Our results underscore the need for intervention and policy efforts that are targeted to specific Asian nationalities, recent immigrants, and individuals without health care access to increase screening rates among Asian women in California. (Am J Public Health. 2015;105:e98–e109. doi:10.2105/AJPH. 2014.302250)
screening among Asian women have persisted over time for many groups.14---19 Asian American women experience significant challenges and barriers to cancer screening, with notable differences by Asian nationality. Some factors associated with this heterogeneity include disparate levels of access to care,20---27 socioeconomic status,26---28 English proficiency,29,30 immigration status and length of US residency,23---25,27,31---33 screening-related knowledge,24,34,35 and health beliefs among Asian women.22,26,35,36 Studies have also documented that several Asian communities tend to use health care services for treatment rather than for prevention.37---39 Available research suggests that Asian American orientation toward preventive behaviors includes using complementary and alternative medicine rather than health care services for prevention of disease and may be influenced by low knowledge levels about the technology of Pap tests and mammograms.40---42 Additionally, studies have found that some Asian American
e98 | Research and Practice | Peer Reviewed | Chawla et al.
communities associate cancer with “a death sentence” and describe fatalism as a barrier to cancer screening.43---45 Until release of the California Health Interview Survey (CHIS), population-based data on Asian Americans were limited by small sample sizes that prevented the ability to disaggregate data on Asian American subgroups. One study that used CHIS data found a wide range of screening rates among Asian American women, with certain groups facing greater disadvantage, such as Vietnamese and Southeast Asian women.46 However, this study did not examine changes in cancer screening trends over time. In our study, we pooled data from the 2001 to 2009 CHIS to assess breast and cervical cancer screening rates for 6 different Asian American subgroups and examined the following research questions: 1. What are the patterns of breast and cervical cancer screening among Asian American
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RESEARCH AND PRACTICE
women in California, and how have they changed over time? 2. Which subgroups of Asian American women have lower screening rates? 3. What differences and similarities exist in factors associated with screening use among Asian Americans? Findings from this research may provide helpful insights for interventions targeting Asian American women and for future research in this diverse population.
METHODS Our study sample was derived from the CHIS, a random-digit-dialed health survey conducted in English, Spanish, and 4 Asian languages (Cantonese, Mandarin, Korean, and Vietnamese).47,48 The 2001 survey was also conducted in Khmer. We pooled data from 5 cycles of CHIS from 2001, 2003, 2005, 2007, and 2009 surveys to help increase the stability of estimates for Asian American nationalities. The weighting factor used for each CHIS cycle was 0.2. We examined Pap test and mammography use among Asian American women overall and among Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese nationalities to explore predictors of cancer screening, detect differences between Asian American ethnic groups, and examine screening trends over time. Pap test receipt was not included in the 2009 CHIS; therefore, results for cervical cancer screening include pooled data from 2001, 2003, 2005, and 2007 only. The overall response rates for the landline and list-assisted adult samples ranged from 37.7% in 2001 to 17.7% in 2009, which are comparable to the Behavioral Risk Factor Surveillance System rates for equivalent years.49,50 We conducted analyses on 7865 Asian American women aged 21 to 64 to assess rates of Pap test receipt and on 4521 Asian American women aged 50 to 74 to assess mammography rates.
Measures Dependent variables. Dependent variables were Pap test receipt in the past 3 years and mammography receipt in the past 2 years. The question used to create the variable for Pap tests was “How long ago did you have your most recent Pap smear test?” Similarly, the item used to create the screening variable for mammography was “How long ago did you
have your most recent mammogram?” Individuals were categorized as “yes” if they received screening tests within the defined time frame and “no” if not. Missing and nonresponse data for these variables were dropped from final analyses. Women who reported a hysterectomy were not included in analyses of Pap test use. Independent variables. Independent variables were survey year, Asian nationality, and sociodemographic, acculturation, and health care access measures. Survey year accounted for changes in screening use over time. Asian nationality was defined by the “Asian9” variable in the CHIS data set, which included Chinese, Filipino, Japanese, Korean, South Asian, Vietnamese, Cambodian, other Southeast Asian, and other Asian/multiple race. We did not conduct nationality-specific analyses for Cambodians, other Southeast Asians, and other Asian/multiple race because of small sample sizes. We tried to combine Cambodians and Southeast Asians into a single group, but the sample size remained too small to produce reliable estimates. All tables present a total column for all Asian Americans; these data include Southeast Asians and other Asian/multiple race. Sociodemographic variables included age (21---29, 30---39, 40---49, 50---64 for Pap testing; and 50---64, 65---74 for mammography), marital status (married or living as married/ other), education (high school education or less, any college or technical school, college graduate or higher), and income (< 200% of federal poverty level; ‡ 200% of federal poverty level). Acculturation variables included percentage of life spent in the United States (0%---24.99%; 25%---49.99%; 50%---99.99%; 100%) and English proficiency (yes/no). Finally, health care access variables included health insurance (uninsured, public only, some private health maintenance organization [HMO], some private non-HMO), having a usual source of care (yes/no), and number of doctor visits in the past 12 months (0, 1---2, 3 or more). We based our variable selection on literature on cancer screening both in the general US population and in the Asian American population. Missing and nonresponse data for independent variables were eliminated from final analyses.
Data Analysis We calculated descriptive statistics for characteristics and screening rates among Asian
February 2015, Vol 105, No. 2 | American Journal of Public Health
American women in our study sample. We examined bivariate associations between screening and independent variables to select relevant predictors of cervical and breast cancer screening among Asian American women. General health status was included in bivariate analyses but subsequently removed from multivariate analyses because of lack of significance with screening. We conducted multiple logistic regressions on selected independent variables. Models stratified by Asian nationality included survey year, sociodemographics, acculturation, and health care access. Models conducted on the aggregate Asian sample included these variables as well as Asian nationality. We calculated predictive margins and 95% confidence intervals. The predictive margins are adjusted percentages directly standardized to the distribution of the covariates for the population that the sample represents.51 All analyses were weighted to address the complex CHIS design and to produce estimates that were representative of the California population. We used SAS 9.2 and SUDAAN 10.0.1 software to conduct all analyses.52,53
RESULTS Table 1 presents descriptive statistics for Asian American women aged 21 to 74 years in the pooled CHIS sample. In the total Asian American sample, most individuals were younger than 50 years (67.8%), were married (70.7%), had some college education or higher (73.4%), had incomes greater than 200% of the federal poverty level (71.6%), had some private HMO insurance (55.4%), had a usual source of care (86.4%), and were English proficient (76.3%). Approximately 1 of 4 women reported that they were US born (22.1%). Beyond these broader trends, Asian American nationalities varied significantly with respect to demographic, acculturation, and health care access characteristics.
Rates of Screening by Survey Year, Age, and Asian Nationality Table 2 presents rates of Pap test and mammography receipt by survey year and age among Asian American women. Pap testing rates remained stable over time, but all rates were below the recommended level of screening, ranging from 77.3% in 2001 to 80.8% in
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American Journal of Public Health | February 2015, Vol 105, No. 2
2101 2188
2384
2532
2003 2005
2007
2009
3034
3216 1320
40–49
50–64 65–74
6360
College graduate
3549
8318
< 200% FPL
‡ 200% FPL
poverty level (FPL)
Income as a % of federal
proficiency
3425
2527
100 English proficiency
8442
3149
50–99.99
Limited or no English
3568
25–49.99
English proficient
2612
0–24.99
% of time in United States
or higher
3250
2257
Any college or technical school
3677
£ High school
Education completed
Other
as married
Married or living
8182
2829
30–39
Marital status
1468
21–29
Age, y
2662
2001
Survey year
No.
1 119 125
443 789
370 998
1 191 917
344 524
414 652
455 347
347 336
851 172
295 552
416 190
457 284
1 104 869
361 784 140 639
364 874
387 044
308 573
333 968
326 264
292 882 323 806
285 994
Pop. Est.
Asian
71.6
28.4
23.7
76.3
22.1
26.5
29.2
22.2
54.5
18.9
26.6
29.3
70.7
23.1 9.0
23.3
24.8
19.7
21.4
20.9
18.7 20.7
18.3
%
2366
942
1039
2269
697
784
1026
800
1877
585
846
1039
2267
971 336
862
745
394
547
731
661 671
698
No.
299 792
136 762
152 266
284 287
79 505
99 584
143 001
114 378
232 631
68 409
135 514
127 334
309 081
103 604 40 944
105 440
104 788
81 778
86 823
89 132
84 067 89 374
87 158
Pop. Est.
Chinese
68.7
31.3
34.9
65.1
18.2
22.8
32.8
26.2
53.3
15.7
31.0
29.2
70.8
23.7 9.4
24.2
24.0
18.7
19.9
20.4
19.3 20.5
20.0
%
1562
481
77
1966
543
636
538
324
1207
497
339
676
1366
580 225
502
476
260
274
456
394 387
532
No.
322 551
93 740
14 754
401 537
95 070
134 141
117 223
69 578
245 676
102 770
67 845
122 344
293 886
111 053 45 735
97 926
91 427
70 151
84 579
92 702
75 394 87 122
76 495
Pop. Est.
Filipino
77.5
22.5
3.5
96.5
22.9
32.2
28.2
16.7
59.0
24.7
16.3
29.4
70.6
26.7 11.0
23.5
22.0
16.9
20.3
22.3
18.1 20.9
18.4
%
1003
154
77
1080
774
208
98
77
633
334
190
445
712
343 196
319
199
100
188
279
212 218
260
No.
103 286
15 461
8713
110 033
78 063
21 896
10 842
7946
61 569
34 464
22 714
34 991
83 755
32 665 22 400
30 293
21 403
11 986
22 653
23 976
25 425 23 171
23 521
Pop. Est.
Japanese
87.0
13.0
7.3
92.7
65.7
18.4
9.1
6.7
51.8
29.0
19.1
29.5
70.5
27.5 18.9
25.5
18.0
10.1
19.1
20.2
21.4 19.5
19.8
%
1325
640
1068
897
144
556
734
528
1121
278
566
536
1427
468 305
565
435
192
551
345
286 353
430
No.
116 315
48 140
79 174
85 280
25 661
42 220
52 660
43 757
98 206
22 145
44 104
49 721
114 399
33 970 12 555
43 209
37 192
37 528
41 423
32 886
30 686 32 893
26 567
Pop. Est.
Korean
70.7
29.3
48.1
51.9
15.6
25.7
32.1
26.6
59.7
13.5
26.8
30.3
69.7
20.7 7.6
26.3
22.6
22.8
25.2
20.0
18.7 20.0
16.2
%
804
149
42
911
93
234
312
314
744
111
98
182
770
154 33
210
366
190
189
209
188 189
178
No.
126 098
22 591
5349
143 340
16 482
33 394
46 209
52 604
116 753
16 909
15 027
27 958
120 702
19 002 3568
29 820
59 747
36 553
37 023
30 182
26 123 34 983
20 378
Pop. Est.
South Asian
84.8
15.2
3.6
96.4
11.1
22.5
31.1
35.4
78.5
11.4
10.1
18.8
81.2
12.8 2.4
20.1
40.2
24.6
24.9
20.3
17.6 23.5
13.7
%
735
932
986
681
56
446
663
499
423
254
990
535
1131
527 175
401
391
173
627
216
220 238
366
No.
48.1
51.9
53.5
46.5
11.4
27.0
33.1
28.6
27.5
16.7
55.9
32.5
67.5
26.9 6.0
21.6
24.3
21.1
21.7
21.8
18.4 20.8
17.3
%
Continued
82 643
89 110
91 806
79 947
19 526
46 280
56 745
49 007
47 157
28 660
95 936
55 858
115 872
46 244 10 320
37 172
41 770
36 247
37 221
37 516
31 648 35 704
29 665
Pop. Est.
Vietnamese
TABLE 1—Sample Characteristics of Asian American Women Aged 21–74 Years, by Nationality, Sample Sizes, Weighted Population Estimates (Pop Est), and Weighted Percentages: California Health Interview Survey, 2001–2009
24.6
42.9 73 603 6.3 9337 81 24.3 39 913 591 15.8 65 922 305 20.2 Note. FPL = federal poverty level; HMO = health maintenance organization.
88 115 674 19.6 2727 Fair/poor
306 436
391 65.3
28.5 42 303
97 050 591
281 35.6
40.1 65 948
58 560 709
664
816 10.4 12 311
42 155
117
32.5 55 842
28.1 312
728 53.3
30.9 128 436
221 933 1123
615 32.0
47.8 208 745
139 482 1045
1588 49.6
30.7 480 381 3667 Good
775 700 5469 Excellent/very good
General health status
1415 85.4
14.6 21 681
127 008 826
127 26.8
73.2 120 429
44 026 419
1546
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458
61.6
33 326
17.0 29 151
73 110
83.0 142 602
8.9
1050
107 9.1
90.9 378 393
37 899 198
1845 87.2
12.8 55 794
380 305 2918
388 13.6
86.4 1 349 278
213 181 1580
10 285 Yes
Has a usual source of care
No or usual source is the emergency department
42.6 63 301 416 44.3 72 781 855 537 45.1 187 281 932 42.4 184 346 1391 44.1 687 266 5305 ‡3
252
91.1
10 529
48.2
108 218
33.8
81 791 823 45.1
57 315
53 472
18.0 30 480 13.4
44.1 65 522
19 866 126
411 30.6
25.1 41 293
50 272 688
420
546 39.6 46 960 461
157 10.4
44.5 184 970
43 134 226
882 39.2
18.4 80 097
170 352 1320
587 16.1
4629 1–2
250 587 1892 0
in past 12 mo
39.8
25.6 38 065 207 13.1 21 503 207 168 18.3 76 306 346 14.8 64 440 488 16.3 255 375 1701 Some private non-HMO No. of times saw a physician
619 703
153
276 15.3 18 109
10.1 17 408 13.3 15 736
5.1
45.4
8781
77 968 675 60.7
1.8 2615
90 246 605
21 3.7
42.1 69 280
6021 72
809
111 1.5
66.7
1828
79 260 747
30 5.4
59.6 247 940
22 685 117
1211 56.7
5.1 22 302
247 559 1957
120 4.4
55.4 Some private HMO
68 111 511
6423
Public only non-HMO
865 037
20.2
19.1
34 756
32 841 457
271 10.1
1.9 2799
14 964 88
32 9.0
32.1 52 853
14 798 298
5.5
12.9
6546 60 8.2
8.4 35 053
34 307 179
190 9.4
14.0 61 126
40 982 342
400 14.2
9.7 151 682
1670
1561 Public only HMO
222 562
152
15 376
579
Multivariate Results
Uninsured
Health insurance
TABLE 1—Continued
2007. In 2007, Chinese (77.5%) and Korean (78.0%) women had the lowest rates of Pap test receipt, whereas Japanese women had the highest (85.5%). A trend across Asian American nationalities was that women between ages 21 and 29 had the lowest rates of Pap testing compared with other age groups. Mammography rates for Asian American women in aggregate rose from 76.0% in 2001 to 82.6% in 2009. In disaggregated analyses, mammography rates rose over time for most Asian American ethnic groups, with the greatest increases among Vietnamese, Chinese, and Japanese women. However, rates of mammography may have declined among South Asian women between 2001 and 2009. Relative to the Healthy People 2020 recommendations, all Asian nationalities met the objectives of 81.1% except Korean (64.7%) and South Asian (69.7%) women in 2009.
Predictive margins calculated from multivariate results for Pap test and mammography receipt, respectively, are presented in Tables 3 and 4. Pap test rates remained stable over time, with no significant changes by survey year for nearly all Asian nationalities with the exception of South Asian women who increased screening rates from 72.5% in 2001 to 83.4% in 2007 (Table 3). Results among Asian women in aggregate, which are presented in the first regression column, indicated that Filipino women were more likely to receive Pap tests compared with Chinese women (83.5% vs 77.6%; P < .001). Asian American women who were aged 30 to 39 years and 40 to 49 years were significantly more likely to have Pap tests compared with those aged 21 to 29 years for all Asian American ethnic groups except Korean women. Unmarried women from all Asian American ethnic groups, except Korean women, were significantly less likely to receive Pap tests compared with their married counterparts. This difference was particularly striking for South Asian women (83.8% vs 56.2%; P < .001). Asian American women in aggregate, Filipino women, and Korean women with less than a college degree were less likely to receive Pap tests compared with college graduates. Asian American women who spent more time in the United States were more likely to report Pap test receipt. This finding was true for Asian American
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American Journal of Public Health | February 2015, Vol 105, No. 2
1818
1870
1923
1251
2331
2210
2073
7865
2003
2005
2007
Age, y 21–29
30–39
40–49
50–64
Total
1198
2007
2009
1315
4521
65–74
Total
80.1 (78.3, 81.7)
79.5 (76.4, 82.3)
80.3 (78.0, 82.4)
82.6 (77.2, 86.9)
81.2 (77.7, 84.3)
80.2 (76.4, 83.6)
76.0 (72.1, 79.4) 79.1 (75.3, 82.4)
79.0 (77.6, 80.4)
82.0 (79.8, 84.0)
85.3 (83.3, 87.1)
83.2 (81.2, 85.1)
63.6 (59.3, 67.6)
80.8 (77.6, 83.6)
78.3 (75.0, 81.2)
79.6 (76.8, 82.1)
77.3 (74.9, 79.6)
% (95% CI)
Asian
1306
335
971
251
340
253
206 256
2344
692
659
634
359
594
586
560
604
No.
78.4 (75.2, 81.3)
79.2 (72.7, 84.4)
78.1 (74.2, 81.5)
81.2 (71.4, 88.3)
83.3 (79.1, 86.8)
82.4 (76.3, 87.1)
71.9 (63.6, 79.0) 72.7 (63.8, 80.0)
75.1 (72.5, 77.5)
80.9 (76.8, 84.5)
84.0 (80.2, 87.1)
79.4 (75.3, 82.9)
53.8 (46.7, 60.8)
77.5 (71.4, 82.6)
76.6 (71.4, 81.1)
73.5 (68.4, 78.1)
72.5 (67.6, 76.9)
% (95% CI)
Chinese
799
224
575
157
196
152
156 138
1466
396
412
426
232
351
322
351
442
No.
No.
737
222
249
176
82.6 (78.3, 86.2)
79.1 (72.0, 84.7)
84.1 (78.6, 88.4)
82.6 (70.6, 90.4)
83.4 (74.9, 89.4)
79.9 (70.3, 87.0)
81.1 (71.8, 87.9) 86.6 (79.3, 91.6)
90
205
168
162
202
539
196
343
106
144
100
88 101
Mammography
86.6 (83.8, 89.0)
90.0 (86.2, 92.8)
91.7 (87.9, 94.4)
88.7 (83.8, 92.3)
73.5 (63.8, 81.4)
82.2 (75.9, 87.1)
85.6 (78.6, 90.5)
91.8 (86.3, 95.2)
87.4 (82.6, 91.0)
Papanicolaou Test
% (95% CI)
Filipino
86.1 (81.9, 89.5)
90.1 (83.0, 94.4)
83.4 (77.6, 88.0)
93.3 (83.3, 97.5)
86.4 (77.4, 92.2)
80.0 (68.4, 88.1)
82.0 (69.4, 90.2) 88.8 (78.0, 94.7)
82.7 (78.4, 86.4)
81.6 (73.6, 87.6)
91.0 (86.0, 94.3)
85.4 (76.4, 91.4)
63.9 (48.4, 77.0)
85.5 (76.2, 91.6)
85.4 (78.3, 90.4)
78.3 (67.7, 86.2)
82.1 (72.9, 88.7)
% (95% CI)
Japanese
772
305
467
274
147
125
134 92
1166
275
391
347
153
266
294
249
357
No.
65.2 (59.3, 70.7)
63.8 (53.8, 72.8)
65.7 (58.3, 72.4)
64.7 (52.6, 75.1)
64.4 (51.1, 75.7)
69.1 (53.3, 81.4)
57.6 (46.1, 68.3) 68.7 (54.2, 80.4)
73.0 (69.0, 76.7)
69.0 (61.0, 75.9)
77.7 (72.4, 82.3)
76.9 (71.1, 81.9)
64.4 (50.1, 76.5)
78.0 (69.3, 84.8)
70.0 (62.0, 76.9)
70.9 (61.4, 78.9)
72.9 (67.7, 77.6)
% (95% CI)
Korean
186
33
153
47
44
36
30 29
711
99
151
296
165
192
176
180
163
No.
79.5 (71.3, 85.8)
81.9 (50.3, 95.3)
79.0 (70.4, 85.7)
69.7 (54.3, 81.6)
82.8 (56.3, 94.8)
84.0 (59.3, 95.0)
91.6 (73.1, 97.7) 79.0 (59.4, 90.6)
79.4 (75.1, 83.2)
81.7 (67.7, 90.5)
85.3 (79.0, 90.0)
84.8 (78.1, 89.8)
65.5 (55.1, 74.7)
79.7 (68.9, 87.4)
80.7 (73.2, 86.5)
80.7 (71.3, 87.5)
75.2 (66.4, 82.3)
% (95% CI)
South Asian
699
173
526
302
89
99
125 84
900
279
228
277
116
190
206
190
314
No.
82.2 (77.2, 86.3)
78.8 (67.0, 87.1)
83.0 (77.2, 87.6)
93.6 (89.9, 96.0)
76.9 (63.0, 86.7)
82.4 (70.1, 90.4)
75.9 (65.2, 84.1) 80.0 (64.7, 89.7)
76.1 (72.1, 79.7)
78.1 (71.1, 83.8)
76.6 (68.2, 83.4)
81.5 (74.7, 86.8)
65.6 (53.1, 76.2)
84.6 (77.2, 90.0)
75.7 (66.8, 82.8)
72.2 (62.8, 80.0)
69.3 (62.1, 75.7)
% (95% CI)
Vietnamese
Note. CI = confidence interval. Women who reported a hysterectomy were not asked the Papanicolaou test questions in 2005, so they were excluded from all years for consistency. The Papanicolaou test questions were not asked for the CHIS 2009 survey. Percentages are percentages of the row total.
3206
50–64
Age, y
799
1010
2005
778 736
2001 2003
Survey year
2254
2001
Survey year
No.
TABLE 2—Weighted Percentages of Papanicolaou Test and Mammography Use Reported by Asian American Women, by Nationality, Age, and Survey Year: California Health Interview Survey (CHIS), 2001–2009
81.2 (78.4, 83.9)
2007
81.4*** (79.2, 83.6)
50–65 Marital status
February 2015, Vol 105, No. 2 | American Journal of Public Health
77.1 (74.0, 80.2)
78.2 (75.6, 80.7)
79.5 (77.8, 81.3)
< 200% FPL
‡ 200% FPL (Ref)
level (FPL)
Income as a % of federal poverty
proficiency
79.8 (78.1, 81.6)
87.8*** (85.6, 90.1)
100
Limited/no English
83.8*** (81.4, 86.2)
50–99.99
English proficiency English proficient (Ref)
77.5*** (74.7, 80.4)
25–49.99
0–24.99 (Ref)
% of time in United States
68.0 (64.9, 71.0)
80.7 (78.8, 82.6)
school College graduate or
higher (Ref)
77.4 (74.6, 80.3)
77.1* (74.2, 80.0)
Any college or technical
69.5*** (66.7, 72.2)
£ High school
Education completed
Other
married (Ref)
83.3 (81.9, 84.6)
84.9*** (83.1, 86.7)
40–49
Married or living as
81.2*** (79.3, 83.2)
30–39
21–29 (Ref)
68.3 (64.3, 72.2)
77.7 (74.9, 80.5)
2005
Age, y
77.9 (75.7, 80.1) 79.5 (77.0, 81.9)
76.6 (73.6, 79.6)
72.4 (67.9, 76.9)
76.2 (71.5, 80.8)
74.7 (71.4, 78.0)
84.9***(80.2, 89.6)
84.1*** (79.1, 89.0)
72.7* (68.5, 76.8)
64.7 (59.7, 69.8)
76.4 (73.0, 79.7)
73.4 (67.9, 78.9)
74.4 (69.7, 79.1)
66.0*** (61.2, 70.8)
79.7 (77.0, 82.4)
79.6*** (75.8, 83.5)
83.7*** (80.5, 87.0)
76.6*** (72.8, 80.4)
61.2 (54.6, 67.8)
78.2 (72.7, 83.7)
75.5 (71.5, 79.4)
73.8 (69.7, 77.8) 73.6 (69.3, 77.8)
PM (95% CI)
PM (95% CI)
2001 (Ref) 2003
Survey year
Chinese
Asian
86.6 (83.6, 89.6)
86.5 (81.7, 91.3)
85.2 (73.1, 97.3)
86.7 (84.0, 89.3)
92.1*** (89.1, 95.0)
90.2*** (86.5, 93.9)
85.8** (80.3, 91.2)
71.8 (63.9, 79.7)
88.7 (85.8, 91.6)
83.2* (78.4, 88.0)
83.8 (77.0, 90.6)
79.5*** (74.6, 84.4)
90.2 (87.6, 92.8)
88.9** (85.3, 92.5)
91.2*** (87.8, 94.6)
88.4** (84.3, 92.6)
76.7 (68.7, 84.8)
82.2 (77.2, 87.3)
86.6 (81.4, 91.7)
86.5 (81.9, 91.0) 91.6 (87.4, 95.8)
PM (95% CI)
Filipino
83.9 (79.7, 88.0)
77.2 (66.1, 88.4)
86.6 (77.1, 96.0)
82.3 (78.1, 86.5)
86.5*** (81.8, 91.2)
83.9** (77.0, 90.8)
82.5** (70.7, 94.3)
53.6 (33.8, 73.4)
81.8 (76.5, 87.2)
84.6 (79.0, 90.2)
82.1 (75.1, 89.2)
76.8** (70.8, 82.7)
85.9 (81.6, 90.1)
75.5 (68.6, 82.3)
88.9** (84.8, 92.9)
88.4* (82.2, 94.6)
75.8 (65.4, 86.2)
85.7 (79.5, 92.0)
81.7 (75.2, 88.2)
82.0 (74.1, 89.9) 81.4 (74.3, 88.5)
PM (95% CI)
Japanese
72.9 (68.1, 77.7)
73.3 (65.4, 81.2)
72.9 (68.0, 77.8)
73.3 (67.5, 79.0)
89.3** (81.2, 97.5)
82.7*** (76.9, 88.6)
68.4 (57.9, 78.9)
64.4 (57.4, 71.4)
79.5 (74.0, 85.1)
56.3*** (44.4, 68.2)
69.2* (61.5, 76.9)
70.5 (62.8, 78.2)
73.9 (69.8, 78.0)
69.6 (62.6, 76.7)
80.3 (75.8, 84.8)
72.7 (66.6, 78.9)
64.6 (49.0, 80.1)
76.4 (66.7, 86.1)
68.3 (61.6, 75.1)
75.7 (70.5, 81.0) 72.2 (64.8, 79.6)
PM (95% CI)
Korean
78.6 (74.2, 83.1)
82.8 (74.4, 91.1)
65.4 (44.8, 85.9)
79.9 (75.8, 84.0)
93.1*** (88.7, 97.5)
82.3* (74.4, 90.1)
84.7** (78.3, 91.1)
69.8 (62.9, 76.8)
79.0 (74.5, 83.5)
81.1 (71.3, 90.9)
80.5 (69.1, 92.0)
56.2*** (44.2, 68.3)
83.8 (80.2, 87.3)
79.0 (65.6, 92.4)
84.4* (78.7, 90.1)
82.4* (76.8, 88.0)
73.1 (65.4, 80.9)
83.4* (76.8, 90.0)
79.3 (72.3, 86.3)
72.5 (65.0, 80.1) 79.8 (72.7, 87.0)
PM (95% CI)
South Asian
Continued
76.4 (69.7, 83.2)
75.5 (69.6, 81.4)
71.6 (65.3, 77.9)
81.6 (75.5, 87.8)
94.6** (88.2, 100.0)
78.8* (71.0, 86.6)
74.6* (67.1, 82.0)
65.3 (58.3, 72.3)
74.9 (66.2, 83.6)
73.3 (62.8, 83.9)
76.8 (72.0, 81.7)
63.0*** (54.5, 71.5)
81.4 (77.2, 85.5)
82.9*** (77.7, 88.1)
77.5** (70.5, 84.4)
76.6* (70.1, 83.2)
58.6 (46.5, 70.7)
81.5 (74.4, 88.6)
75.3 (67.7, 83.0)
72.7 (66.5, 78.8) 74.0 (66.6, 81.4)
PM (95% CI)
Vietnamese
TABLE 3—Predictive Margins (PMs) From Multivariate Analyses for Asian American Women Aged 21–65 Years, by Nationality Reporting a Papanicolaou Test in the Past 3 Years: California Health Interview Survey, 2001–2009
RESEARCH AND PRACTICE
Chawla et al. | Peer Reviewed | Research and Practice | e103
78.3 (71.8, 84.7)
74.8 (68.0, 81.7)
Southeast Asian
Other/multiple
Asian types
78.6 (74.8, 82.4) 80.0 (76.5, 83.5) South Asian Vietnamese
75.0 (70.3, 79.6)
76.8 (72.8, 80.7) Korean
Japanese
77.6 (75.4, 79.8)
83.5** (80.6, 86.3) Filipino
Chinese (Ref)
emergency department
Asian nationality
e104 | Research and Practice | Peer Reviewed | Chawla et al.
Note. CI = confidence interval; HMO = health maintenance organization. The weighting factor used for each CHIS cycle was 0.2. Women who reported a hysterectomy were not asked the Papanicolaou test questions in 2005, so they were excluded from all years for consistency. The Papanicolaou test questions were not asked for the CHIS 2009 survey. *P < .05; **P < .01; ***P < .001.
76.0 (71.8, 80.2) 75.1 (65.7, 84.5) 81.6 (77.2, 86.1) 71.0 (59.1, 83.0) 72.8 (67.9, 77.7) 73.6 (64.4, 82.8) 83.4 (79.0, 87.8) 79.2 (68.3, 90.1) 87.5 (84.8, 90.2) 82.0 (73.5, 90.5) 76.0 (73.3, 78.7) 72.0 (64.9, 79.1) 79.9 (78.5, 81.3) 75.7* (71.7, 79.7) Yes (Ref) No or usual source is
Has a usual source of care
78.2 (71.9, 84.4)
80.3 (75.3, 85.3) 87.0 (81.7, 92.3) 81.9 (76.3, 87.4) 88.0 (83.0, 93.0) 82.8 (79.4, 86.3) ‡ 3 (Ref)
84.8 (83.0, 86.6)
89.9 (86.4, 93.5)
60.4*** (49.9, 70.9) 71.9** (62.2, 81.7)
75.6** (69.7, 81.6) 74.6* (68.8, 80.4)
58.8** (49.8, 67.8) 57.7*** (45.9, 69.5)
88.7 (84.1, 93.3) 86.4 (83.1, 89.7) 76.0** (72.1, 79.8) 80.1*** (78.0, 82.1)
76.6** (67.7, 85.4) 60.8*** (54.9, 66.7) 65.1*** (61.3, 68.9) 0
in past 12 mo
No. of times saw a physician
77.2 (73.7, 80.7) 76.0 (70.7, 81.4) 80.7 (78.6, 82.8) 78.7 (75.8, 81.7)
1–2
77.6 (70.7, 84.5) 83.3 (71.8, 94.8) 82.8 (77.4, 88.1) 80.0 (72.6, 87.3) 76.6 (69.7, 83.5) 69.4 (59.1, 79.8) 83.3 (77.8, 88.7) 86.9 (79.5, 94.4)
72.8 (63.9, 81.7)
Some private HMO (Ref) Some private non-HMO
85.9 (81.9, 89.9) 84.5 (79.6, 89.3)
72.7 (37.5, 100.0)
63.2** (48.3, 78.2) 69.5 (62.8, 76.2)
79.9 (70.2, 89.6) 66.4 (46.9, 85.9)
78.0 (64.8, 91.1) 88.7 (83.4, 94.1)
74.6 (65.4, 83.8) 79.2 (75.1, 83.3)
92.2 (85.2, 99.1)
69.2* (63.5, 75.0) 75.2** (72.2, 78.3)
Public only
Uninsured
Health insurance
TABLE 3—Continued
73.8 (66.8, 80.7)
RESEARCH AND PRACTICE
women aggregated and all Asian American ethnic groups, with US-born Asian women reporting the highest screening rates. Women from all Asian American ethnic groups with fewer physician visits in the past 12 months also had lower Pap test rates compared with those with 3 or more visits. Uninsured Asian women in aggregate and uninsured South Asian and Chinese women were less likely to report receiving a Pap test compared with their insured counterparts, but this finding was not consistent for the other Asian nationalities. Table 4 presents the multivariate results for mammography receipt, which indicate an upward trend over time, with increasing rates of mammography for Asian American women overall and Chinese, Japanese, and Vietnamese women between 2001 and 2009. In 2009, Japanese (93.8%) and Vietnamese (92.9%) women had the highest rates of mammography receipt (83.9%), whereas Korean (63.3%) and South Asian (73.0%) women had the lowest after controlling for other factors. Among Asian American women in aggregate, Korean women were less likely than Chinese women to receive mammograms (72.1% vs 80.3%; P < .01), whereas Vietnamese women were more likely (86.3% vs 80.3%; P < .05). Unmarried Asian women in aggregate, Filipino women, and South Asian women were less likely to receive mammograms compared with married women. Neither education nor income level was a significant predictor of mammography receipt. Women who reported being in the United States for longer reported higher mammography rates, except Korean, South Asian, and Vietnamese women. Compared with women with 3 or more physician visits in the past year, Asian women with fewer visits had significantly lower rates of mammography. Notably, uninsured Asian women overall, Filipino women, and Japanese women were less likely to report receiving a mammogram; additionally, Asian women overall, Chinese women, and Vietnamese women without a usual source of care were also less likely to receive mammograms in the past 2 years.
DISCUSSION The purpose of our study was to examine patterns of cervical and breast cancer screening among Asian American women in California
American Journal of Public Health | February 2015, Vol 105, No. 2
80.6 (77.1, 84.0) 81.8* (78.5, 85.1) 81.8* (77.5, 86.0)
2005
2007
2009
February 2015, Vol 105, No. 2 | American Journal of Public Health
82.0 (80.2, 83.8)
79.6 (75.2, 83.9) 84.5 (82.1, 86.9) 75.6** (68.6, 82.7)
Public only Some private HMO (Ref)
Some private non-HMO
Uninsured
69.6*** (63.7, 75.6)
‡ 200 FPL (Ref)
Health insurance
79.6 (76.8, 82.5) 80.2 (77.7, 82.7)
< 200 FPL
level (FPL)
Income as a % of federal poverty
English proficient (Ref) Limited/no English proficiency
81.0 (78.4, 83.6) 78.4 (75.0, 81.7)
86.2*** (81.9, 90.4)
English proficiency
82.6*** (79.7, 85.5)
100
80.6*** (77.5, 83.7)
50–99.99
25–49.99
0–24.99 (Ref)
70.9 (65.7, 76.1)
80.6 (77.9, 83.2)
College graduate or higher (Ref) % of time in the United States
0–49.99 (Ref)
80.2 (76.6, 83.9) 78.0 (73.7, 82.3)
Any college or technical school
74.7*** (70.9, 78.5)
£ High school
Education completed
Other
Married or living as married (Ref)
Marital status
50–64 (Ref) 65–74
80.7 (78.3, 83.0) 78.2 (74.3, 82.1)
78.8 (75.1, 82.4)
Age, y
75.6 (72.0, 79.3)
2003
75.5 (65.5, 85.5)
77.0 (67.7, 86.3) 81.7 (76.5, 86.8)
71.3 (60.6, 81.9)
80.3 (76.4, 84.1)
75.7 (70.0, 81.5)
79.7 (74.7, 84.7) 77.1 (72.3, 82.0)
86.1** (79.7, 92.5)
76.0 (69.1, 82.9)
81.5* (76.8, 86.3)
72.3 (65.8, 78.9)
78.3 (73.4, 83.1)
71.5 (62.9, 80.1)
80.6 (76.4, 84.8)
76.5 (70.0, 83.0)
78.8 (75.4, 82.3)
77.8 (73.1, 82.5) 79.3 (71.1, 87.5)
81.4* (75.0, 87.7)
83.8** (79.9, 87.6)
81.7* (75.6, 87.9)
73.0 (65.2, 80.8)
70.2 (61.9, 78.6)
PM (95% CI)
PM (95% CI)
2001 (Ref)
Survey year
Chinese
Asian
73.8** (61.9, 85.7)
81.1* (74.2, 88.1) 89.3 (85.4, 93.3)
63.5** (43.5, 83.6)
82.4 (77.7, 87.1)
82.7 (76.6, 88.8)
82.7 (78.5, 87.0) 80.1 (67.3, 92.9)
83.5* (73.9, 93.0)
87.4*** (82.7, 92.1)
84.5** (79.0, 90.0)
65.9 (55.3, 76.6)
82.7 (78.6, 86.8)
84.7 (78.0, 91.4)
80.1 (71.1, 89.2)
75.5** (68.4, 82.6)
86.2 (82.4, 90.0)
84.1 (79.7, 88.5) 79.1 (72.1, 86.0)
84.2 (77.8, 90.6)
83.1 (76.2, 90.1)
81.6 (73.8, 89.3)
83.8 (77.1, 90.5)
78.8 (69.8, 87.8)
PM (95% CI)
Filipino
75.2* (59.2, 91.3)
90.6 (84.6, 96.6) 89.2 (84.9, 93.5)
36.6*** (6.9, 66.2)
86.0 (82.1, 89.9)
86.7 (79.7, 93.7)
85.2 (81.0, 89.4) 91.9 (84.9, 98.8)
89.7*** (86.0, 93.4)
83.0* (75.5, 90.4)
—
—
65.0 (45.9, 84.2)
85.4 (79.8, 91.0)
86.0 (80.8, 91.3)
87.2 (81.6, 92.8)
86.1 (81.7, 90.6)
86.1 (81.6, 90.5)
86.8 (82.6, 91.0) 84.7 (78.4, 91.0)
93.8** (89.6, 97.9)
86.5 (80.5, 92.5)
83.1 (74.7, 91.5)
86.3 (79.2, 93.5)
80.8 (72.4, 89.2)
PM (95% CI)
Japanese
71.5 (54.5, 88.5)
68.1 (56.4, 79.8) 68.7 (57.6, 79.7)
58.9 (48.1, 69.7)
68.9 (61.1, 76.7)
60.9 (52.5, 69.2)
69.4 (59.8, 79.0) 64.1 (57.3, 70.8)
79.6 (55.2, 100.0)
69.7 (59.6, 79.9)
63.0 (55.6, 70.5)
63.7 (53.6, 73.9)
70.0 (62.7, 77.3)
65.3 (54.7, 76.0)
62.5 (54.8, 70.3)
60.1 (51.4, 68.8)
67.0 (60.8, 73.1)
67.1 (59.6, 74.6) 60.8 (49.8, 71.8)
63.3 (52.5, 74.1)
63.3 (53.4, 73.2)
66.5 (55.3, 77.6)
69.1 (58.4, 79.7)
63.7 (54.2, 73.1)
PM (95% CI)
Korean
80.6 (62.4, 98.8)
73.0 (39.2, 100.0) 82.9 (74.9, 90.9)
70.3 (48.9, 91.8)
78.8 (70.6, 86.9)
81.6 (62.9, 100.0)
79.9 (72.7, 87.1) 74.4 (31.5, 100.0)
86.5 (60.3, 100.0)
83.8 (74.2, 93.4)
95.6*** (89.3, 100.0)
58.9 (34.4, 83.5)
76.5 (65.9, 87.1)
82.1 (63.8, 100.0)
85.7 (71.3, 100.0)
56.1* (31.8, 80.4)
87.1 (77.2, 97.0)
76.5 (67.2, 85.8) 90.4 (70.9, 100.0)
73.0 (64.7, 81.2)
76.0 (58.8, 93.2)
90.4 (81.8, 98.9)
74.4 (53.4, 95.4)
86.9 (64.9, 100.0)
PM (95% CI)
South Asian
Continued
90.8 (79.6, 100.0)
79.9 (71.7, 88.2) 86.0 (76.4, 95.7)
77.3 (68.4, 86.3)
75.8 (62.9, 88.7)
83.8 (79.2, 88.4)
85.5 (75.0, 96.1) 81.2 (75.9, 86.6)
—
83.9 (73.7, 94.1)
83.3 (76.3, 90.4)
80.1 (72.4, 87.7)
83.4 (72.4, 94.4)
74.5 (58.5, 90.4)
82.4 (77.4, 87.4)
85.6 (78.8, 92.4)
80.1 (74.0, 86.2)
83.2 (77.9, 88.4) 76.3 (65.7, 86.9)
92.9*** (89.2, 96.7)
82.7 (73.0, 92.4)
80.7 (69.4, 92.0)
78.1 (64.7, 91.5)
72.9 (62.3, 83.4)
PM (95% CI)
Vietnamese
TABLE 4—Predictive Margins (PMs) From Multivariate Analyses for Asian American Women Aged 50–74 Years, by Nationality Reporting a Mammogram in the Past 2 Years: California Health Interview Survey (CHIS), 2001–2009
RESEARCH AND PRACTICE
Chawla et al. | Peer Reviewed | Research and Practice | e105
78.6 (71.6, 85.6) 86.3* (82.7, 90.0)
78.2 (65.1, 91.3)
83.3 (73.7, 92.9)
South Asian Vietnamese
Southeast Asian
Other/multiple Asian types
e106 | Research and Practice | Peer Reviewed | Chawla et al.
Note. CI = confidence interval; HMO = health maintenance organization. Sample for Japanese living in United States for 0%–24.99% and 25%–49.99% had to be combined because of small cell sizes. The weighting factor used for each CHIS cycle was 0.2. *P < .05; **P < .01; ***P < .001.
79.2 (73.7, 84.6)
72.1** (67.2, 77.0) Korean
79.5 (75.7, 83.4) Filipino
Japanese
80.3 (77.3, 83.3) Chinese (Ref)
Asian nationality
83.6 (78.9, 88.3)
86.5 (82.1, 91.0)
82.9 (74.4, 91.4)
68.9* (53.8, 84.1) 85.6 (70.5, 100.0)
78.4 (70.8, 86.0) 65.5 (59.0, 72.0)
64.1 (52.6, 75.7) 91.7 (85.1, 98.2)
85.5 (81.5, 89.4) 82.9 (78.7, 87.1)
78.5 (67.2, 89.8) 60.9** (45.2, 76.6)
80.6 (77.4, 83.8) 80.8 (78.9, 82.8)
73.2* (66.8, 79.5) No or usual source is emergency department
Has a usual source of care Yes (Ref)
93.6 (84.7, 100.0) 78.1 (72.2, 83.9) 92.7 (89.0, 96.5) 88.9 (84.9, 92.8) 83.4 (79.0, 87.7) 86.5 (84.5, 88.5) ‡ 3 (Ref)
73.1* (60.3, 85.8)
66.6* (45.6, 87.6) 32.2*** (17.9, 46.6)
62.9** (53.0, 72.7) 89.7 (85.3, 94.1)
44.6*** (26.3, 62.8) 74.4** (63.3, 85.4)
76.9*** (70.6, 83.3) 77.9*** (74.6, 81.3) 1–2
64.0*** (54.8, 73.2) 60.8*** (54.4, 67.2) 0
No. of physician visits in past 12 mo
TABLE 4—Continued
79.1 (74.1, 84.2)
60.6*** (42.6, 78.5)
RESEARCH AND PRACTICE
and to assess their screening trends over time. Our findings indicate that rates of Pap test receipt were consistently below Healthy People 2020 objectives for all Asian nationalities and that mammography receipt was below these objectives for certain groups. In examining trends over time, we found no significant changes in Pap test rates, but mammography use increased among Asian American women overall, especially among Chinese and Vietnamese women. Our study confirmed striking variation among Asian American groups, with screening rates varying from 64.7% to 93.6% for mammography receipt in 2009 and from 77.5% to 85.5% for Pap test use in 2007. Notably, Chinese and Korean women had the lowest Pap test rates in 2007, and Korean and South Asian women had the lowest mammography rates in 2009. Therefore, these groups should be the focus of culturally based targeted interventions or programs to promote breast and cervical cancer screening among Asian American women. Several potential factors could help explain the variation among Asian women that we observed. One of the most consistent findings among all Asian American nationalities was that longer time in the United States was associated with increased use of cancer screening for both Pap test and mammography receipt. Surprisingly, English language proficiency was not associated with screening use. This finding could be associated with California’s relatively high proportion of in-language services offered in Asian languages, particularly in areas with a high population density of Asian Americans. Within Asian ethnic enclaves, such as Koreatown or Chinatown, for example, services are offered by health care providers of the same cultural and linguistic background.54,55 Longer time in the United States may result in changing knowledge and attitudes about the use of preventive health care services. This could help explain why increased length of time in the United States was significantly associated with higher screening rates among nearly all Asian American groups, despite lower English proficiency. More time in the United States may also enable women to have better access to and navigation of the US health care system.
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Sociodemographic and health care access factors had varied effects, with education and insurance coverage being significant predictors of screening for certain groups but not all. Contrary to expectations, income level and usual source of care did not appear to play a significant role for most women. For most groups, neither income nor insurance was a significant predictor of mammography or Pap test receipt in multivariate results. This finding is likely a result of a combination of factors. First, California State policies and programs may increase access to screening among Asian women independent of health insurance coverage. The Every Woman Counts program, cofunded by the Centers for Disease Control and Prevention and the state of California, provides in-language services to uninsured and lower-income Asian women and has more generous eligibility criteria in California than in other states.56 The Every Woman Counts program is supplemented by funding for emergency treatment from the federal government and the California tobacco tax, sometimes in collaboration with ethnic community groups. Second, a long-standing network of community-based organizations in California provide primary care services and focus outreach and education efforts on Asian Americans.41,42,57---59 Community-based organizations also work closely with California’s state-based and federal programs as well as ethnic-specific clinics to improve preventive care among Asian individuals in California. Third, several community-based organizations and clinics provide in-language navigation services, which have also been shown to improve preventive care use. Finally, California has a large HMO penetration rate, and HMOs promote the use of preventive care services.60---62 Given this context, California’s state policies and organizations targeting screening in Asians may help explain relative improvements in screening for particular Asian groups (e.g., mammography among Vietnamese women) that we found in our study. Therefore, California may provide a model of health care delivery for increasing cancer screening use among underserved ethnic populations locally and in other states. However, it is important to note that despite the availability of a variety of screening and education programs in California, we still found low and variable rates of cancer screening for breast and
cervical cancers, suggesting that underlying cultural attitudes and beliefs may play a stronger role than has been shown to date. Our study had some limitations that should be noted. First, response rates ranged from 37.7% to 17.7% during the cycles of CHIS included in our analyses and may affect generalizability of findings.49,50 However, these rates are comparable to other random-digitdial samples during the same period, such as the Behavioral Risk Factor Surveillance System.63,64 Second, the CHIS did not include measures of culturally framed health beliefs and attitudes, which may play an important role in screening behaviors and could explain some of the variation observed between groups. Thus, we were limited in our ability to explain how cultural views may affect screening for breast and cervical cancer among Asian American women. Third, for Asian women who were not offered the survey in their native language, the sample captured was more likely to include English-speaking, acculturated women who also may be more likely to be screened. Fourth, data were self-reported. Last, data were cross-sectional, prohibiting us from making causal inferences. Despite these limitations, our study had several strengths. Importantly, these findings were based on several years of pooled data that provided larger sample sizes than in other data on Asian Americans. Unlike other populationbased surveys, the CHIS was conducted in several Asian languages, which helped capture a larger, more representative sample of Asian Americans in California. CHIS data also included several important measures of sociodemographic, acculturation, and health care access factors, enabling us to examine the role of these factors in screening use among Asian American women. Finally, by measuring differences in survey year with the pooled data, we were able to detect an increase in mammography use among Asian women between 2001 and 2009. In conclusion, our findings have several implications and directions for future research. Population-based surveys should incorporate measures of health beliefs and attitudes toward health, prevention of disease, health care use, and the capacity to navigate the complex health care system to better address barriers to screening among Asian Americans. Additional
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research that uses diverse methodological approaches, such as qualitative studies, is needed to tease out the specific barriers to screening for Asian women, including structural barriers such as transportation and out-of-pocket costs, cultural and health beliefs, attitudes toward cancer, and understanding of the basic message that screening use may help prevent the onset of disease. Studies are also needed to assess the cultural sensitivity of health care practitioners and to better understand the role of patient--provider interaction and trust in providers among Asian American women. Perhaps most important, our results underscore the need for targeted interventions to increase rates of mammography and Pap test use among specific Asian nationalities. j
About the Authors Neetu Chawla is with Outcomes Research Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD. Nancy Breen is with Health Services and Economics Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute. Benmei Liu is with Statistical Methodology and Applications Branch, Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute. Richard Lee is with Information Management Services, Inc, Calverton, MD. Marjorie Kagawa-Singer is with UCLA School of Public Health and Asian American Studies Department, Los Angeles, CA. Correspondence should be sent to Neetu Chawla, PhD, MPH, Outcomes Research Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Dr, Rockville, MD 20850 (e-mail:
[email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted August 8, 2014.
Contributors N. Chawla, N. Breen, and M. Kagawa-Singer contributed to the conceptualization and design of the study, data analysis and interpretation, and writing of the article. B. Liu contributed to data analysis, interpretation of results, and writing of the article. R. Lee contributed to data analysis and interpretation.
Acknowledgments The authors would like to acknowledge the support of the Cancer Prevention Fellowship Program for this research. Findings from this study have been presented at the American Public Health Association Research Meeting, October 27---31, 2012, San Francisco, CA.
Human Participant Protection Human subjects’ approval for recruitment and data collection for the California Health Interview Survey was obtained from UCLA and the state of California. Therefore, the survey was exempted from review by the National Institutes of Health, Office of Human Subjects Research Protection.
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